Pediatric Inpatient Discharge Summary

Patient name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Age: [Chronologic age; include corrected gestational age if applicable]

Admit date/time: [Admit date and time]

Discharge date/time: [Discharge date and time]

Service: [Inpatient service]

Attending physician: [Attending name and credentials]

Primary team: [Primary inpatient team/unit]

Primary care clinician/practice: [Name and practice] — [Contact information]

Discharge disposition: [home / home with services / transfer / other]

Caregiver(s) receiving instructions: [Name(s), relationship(s)] — [Preferred language] — [Interpreter used: yes / no]

Reason for Hospitalization

[Chief concern or reason for admission, working diagnosis at presentation, and key severity markers such as hypoxia, dehydration, or altered mental status if applicable] (Format as 2–4 sentences in paragraph form.)

Discharge Diagnoses

• Principal diagnosis: [Single diagnosis primarily responsible for hospitalization] (If uncertain, use a qualifier such as "Possible" or "Presumed.")
• [Secondary diagnosis/comorbidity that affected care or follow-up]
• [Additional relevant diagnoses as needed]

Hospital Course

(Organize by problem. List highest-risk or most clinically important problems first. Reference consultations within the relevant problem when they materially changed care.)

[Problem name 1]

• Assessment: [Key findings supporting the diagnosis; pertinent exam, vitals, labs, or imaging that define severity or trajectory]
• Hospital management: [Treatments provided, response, complications if any, and important care milestones]
• Discharge status: [resolved / improving / stable] — [Residual symptoms or supports at discharge]
• Outpatient plan: [Actionable caregiver tasks, monitoring parameters, outpatient tests with responsible party and timeframe, referrals or follow-up needs]

[Problem name 2]

• Assessment: [Key findings]
• Hospital management: [Summary]
• Discharge status: [resolved / improving / stable] — [Details]
• Outpatient plan: [Action items and timeframes]

(Add additional problems as needed.)

Key Studies, Procedures, and Consultations

(Include this section when notable imaging, microbiology, procedures, or subspecialty consultations occurred. Omit this section entirely if nothing notable. If any test result is pending, ensure it also appears in Pending Results with ownership assigned.)

• [Date] — [Imaging modality and region]: [Notable findings]
• [Date] — [Microbiology test]: [Final organism/susceptibilities or "no growth"]
• [Date] — [Procedure/surgery]: [Indication and outcome]
• [Date] — [Consulting service]: [Key recommendations that persist after discharge]

Condition at Discharge

[Overall clinical status: stable / improving] — [Vital sign stability, respiratory status, hydration/nutrition status, neurologic status, wound or device status if applicable, and functional status including feeding tolerance, urine output, and activity level] (Keep concise; focus on findings relevant to safe transition.)

Discharge Medications

Discharge weight for dosing: [Weight in kg] ([Date measured])

(If no medications are prescribed, state "No medications prescribed at discharge.")

New

• [Generic name] — [formulation] — [route] — [dose in mg] ([mg/kg calculation]) — [frequency] — [duration/stop date] — [indication] (For liquids: [concentration mg/mL], give [mL per dose]. For PRN: [symptom trigger], max [frequency].)

Changed

• [Generic name] — [updated dose/frequency/formulation] — [indication] — [Rationale for change] (Include mg/kg calculation and mL per dose for liquids.)

Continued

• [Generic name] — [formulation] — [route] — [dose and frequency] — [indication] (For liquids: include concentration and mL per dose.)

Stopped

• [Generic name] — [Rationale for discontinuation]

Allergies

[Drug allergies with reaction type; clarify intolerance versus true allergy when known] (If none, state "No known drug allergies.")

Follow-Up Plan

• Primary care: [Clinician/practice] — [Purpose] — [Target timeframe or scheduled date] — [Contact information]
• Specialty follow-up: [Clinician/service] — [Purpose] — [Target timeframe or scheduled date] — [Contact information]
• Home services/equipment: [Service or DME] — [Vendor/contact] — [Start date/delivery] (Include only if applicable.)
• Post-discharge clinical questions: [Contact name/role] — [Phone number] — [Hours/availability]

Pending Results at Discharge

(If none, state "None." Never list a pending test without assigned ownership.)

• [Test name] ([Date obtained]) — [Pending component] — Responsible: [Clinician/service] — Family notification: [How and when]

Caregiver Discharge Instructions

(Use plain language with short sentences. Avoid medical jargon.)

Diagnosis and What to Expect

[Explanation of what the child had, what improved in the hospital, what to expect during recovery, and when symptoms should resolve]

How to Give Medicines

• [Medication name] — Give [mL per dose] by [route] [schedule] for [duration]. [Administration instructions: with spacer / with food / storage if critical]
• [PRN medication] — Give for [symptom]. Maximum [frequency] in 24 hours.

Diet, Hydration, and Activity

• Feeding: [Feeding plan and guidance]
• Hydration: [Targets if relevant]
• Activity: [Restrictions and duration; return-to-sports/PE guidance]

Device or Wound Care

(Include only if applicable.)

• [Device or wound] — [Care steps and frequency] — [Supplies needed] — [When to change/replace]

When to Get Help

Call 911 or go to the Emergency Department now for:

• [Condition-specific red flags such as severe breathing trouble, color changes, unresponsiveness, prolonged seizure]

Call your doctor today for:

• [Worsening symptoms, signs of dehydration, fever recurrence, medication intolerance]

Call for routine questions:

• [Non-urgent concerns, medication refills, appointment questions]

Contacts: [24/7 clinical contact number] — [Scheduling/help number if different]

School/Daycare Clearance

(Include this section when relevant to the discharge.)

• Return criteria: [When child may return]
• Activity restrictions: [PE/sports restrictions and duration]
• School medications: [Medication administration needs and forms provided]
• Infection control: [Guidance if applicable]
• School letter provided: [yes / no]